Jenny Theriot Scenario 2
Spontaneous rupture of membranes (SROM) confirmed by +Nitrazine test and collection of fluid with +Fern test. A Biophysical Profile (BPP) is performed to assess fetal status and amniotic fluid volume, which is found to be decreased. Amniotic fluid continues to leak from vagina. Orders are received to admit to Prenatal Unit and implement Prenatal Premature Rupture of Membranes (PPROM) protocol. An IV of 1000 ml D5W is started to ensure adequate hydration. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:
1Place bed in Trendelenburg position.Assists in relieving pressure of fetal head on cervix, preventing premature cervical dilation; helps in slowing or preventing continuing leaking of amniotic fluid. Fetal safety is critical.
2Discuss plan of care with patient; answer questions honestly, especially concerning SROM and implications for preterm labor and birth.Provision of clear information facilitates compliance with plan of care and can allay anxiety.
3Assess support systems available to woman.Assistance and caring by significant others are important during stressful events.
4Apply sequential compression device (SCD) boots and connect to machine.Prevents the formation of blood clots secondary to immobility.
5Begin Intake and Output (I&O) chart and document every shift.Ensures adequate hydration and balanced elimination.